A New Double Elevating Osteotomy in Management of Severe Neglected Infantile Tibia Vara using the Ilizarov Technique

Abstract

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.

Management of neglected Blount disease using double corrective tibia osteotomy and medial plateau elevation

“…The use of the Ilizarov Frame [15][16][17], the Taylor Spatial Frame [18][19][20], and a Multi-Axial Correction external fixation system [21] are modern therapeutical options, although significantly more expensive than our procedure. These systems enable gradual correction [20], in contrast to our cases, for whom correction was imminent.…”

Correction of Blount's disease by a multi-axial external fixation system

“…The MAC system was developed as a possible alternative to the Ilizarov circular fixator. The surgical treatment of Blount's disease has centered around the use of tibial osteotomies with varying forms of internal or external fixation [11,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29]. Due to the fact that the two institutions involved in this study are large referral centers for Blount's disease, we felt that choosing to analyze this deformity (with its combination of angulation, rotation, and medial column shortening) would be the ideal manner to analyze the MAC system [5][6][7][8].…”

“…Utilizing the Ilizarov fixator as the 'gold standard' in the treatment of Blount's disease [15][16][17][18][19][20][21], there have been several studies that have investigated correction using this method. This allows for a comparison between the results obtained with the MAC system and those of the Ilizarov fixator in terms of radiographic correction, wear time, operative time, and complications.…”

“…Various surgical techniques, including osteotomies, can help to restore alignment of the leg. Reports include the use of circular Ilizarov external fixation [15][16][17][18][19][20][21], non-circular external fixation [22,23], internal fixation [11,24], hemiplateau elevation with/ without epiphyseal distraction [25,26], double elevating osteotomies [27], serrated W/M osteotomies [28], epiphyseal stapling [29], Taylor Spatial Frame correction [30], and hemiepiphysiodesis by guided growth [31]. All of these techniques vary in their ease of application/performance, achievement of (and time to) deformity correction (both clinically and radiographically), prevention of recurrence, and complications (i.e., nerve damage, infection, non-union, mal-union) [12, 14, 16, 17, 22-26, 28, 29, 32, 33].…”

“…The use of the Ilizarov circular fixator in combination with tibial osteotomy has been widely used for the correction of Blount's disease [15][16][17][18][19][20][21]. Advantages of this method include early weight-bearing, early motion, and, most importantly, multi-planar deformity correction (including rotation, angulation, and translation) [17,18].…”